Military Exposures & Your Health - 2022 -Issue #6
In this issue:
- The Individual Longitudinal Exposure Record - An introduction
- Karshi-Khanabad (K-2)
- Resources on military environmental exposures
- Radiation cleanup update- Palomares and Enewetak
- The Airborne Hazards and Open Burn Pit Registry – Purpose and location update
- Whole health at VA
- “She Wears the Boots” podcast covers military exposures
- Breast cancer and post-9/11 women Veterans
- Health effects related to service at Camp Lejeune: Care, benefits, and federal research
- WRIISC study on Veterans and COVID-19
- Research update: VA’s Epidemiology Program, Health Outcomes of Military Exposures
- Gulf War illness and a case definition
The Individual Longitudinal Exposure Record - An introduction
In caring for Veterans with concerns about military environmental exposures from deployment or in garrison/on base, VA is looking for better ways to document these exposures and link them with medical concerns to look for connections between exposures and health outcomes. An improved way to do this is with the Individual Longitudinal Exposure Record, or ILER.
Department of Defense (DoD) environmental technicians and industrial hygienists collect air, soil, and water samples in deployed and garrison environments. They also conduct special surveys in line with Occupational Health and Safety (OSHA) standards at potentially hazardous sites, such as flight lines, ships, and industrial locations like motor pools and other maintenance facilities. This information is used to monitor the health of workers and ensure they have a safe worksite.
In the past, only military commanders and others at DoD could review this information through written reports and in a database called the Defense Occupational and Environmental Health Readiness System (DOEHRS). With VA’s ILER, developed in 2018, VA can now access DOEHRS information in a central location and connect this information to the records of individual service members and Veterans.
ILER contains information on all potential environmental hazards, not just exposures of concern. In fact, most environmental samples in DOEHRS are normal, routine air, soil, and water samples and are not health hazards.
With ILER, VA staff can search for environmental exposure data by person or location through a secure portal. This can be useful for health care providers seeing a patient, or a claims manager evaluating an exposure claim.
Additionally, ILER has another exciting potential application: VA can use it to study or monitor a group of service members or Veterans stationed at a certain location and time. This can be helpful if VA needs to create a registry (a collection of data that allows for research analysis on a specific population) because certain past exposures have become a health concern. ILER can be used to build the registries of the future.
VA is also developing a portal so Veterans can access personal ILER information. Before rolling this out, the VA Information Technology group will conduct pilot testing and collect feedback to help develop a useful product for Veterans.
ILER does have limitations. Data entry in DOEHRS did not start until after 9/11, so ILER does not have information from the eras of the Vietnam War, Desert Shield, or Desert Storm. In addition, not all collected information has been digitized and entered into DOEHRS. VA and DoD will continue to work together to expand the functions and comprehensiveness of ILER so that it can be a useful tool in assessing military exposures going forward.
Karshi-Khanabad (K-2) was a former Soviet-era airbase located in Southwest Uzbekistan. It was occupied by U.S. forces from 2001-2005 to support operations in Afghanistan as part of Operation Enduring Freedom. Given the nature of the original Soviet airbase, a series of environmental site surveys were conducted during the K-2 occupation (Search: Karshi Khanabad- Army Public Health Center). Several low-level toxic exposures were documented at this site, and health complaints have garnered the interest of media outlets and Congress.
In December 2020, Public Law 116-315 was passed. The VA Secretary was directed to enter into an agreement with the Centers for Disease Control and Prevention’s (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) to: 1) prepare a summary report of the conditions at K-2; and 2) assess the health effects in those deployed to K-2, with a final report due no later than January 2030. This agreement includes establishing a community engagement panel to provide updates to K-2 Veterans and other stakeholders, as well as provide an opportunity for K-2 Veterans and stakeholders to communicate with VA.
ATSDR staff are leading the effort to prepare a summary report on exposures at K-2, with a final report anticipated by the summer of 2022. VA’s Epidemiology Program within Health Outcomes of Military Exposures is responsible for assessing the possible health impacts from serving at K-2, with ATSDR serving as consultants.
The Epidemiology Program has designed a prospective surveillance program, called the K-2 Surveillance Program (K2SP). K2SP includes a longitudinal health database for all K-2 Veterans and two comparison groups: one group that deployed to Southwest Asia, but not to K-2, and a second group that served during the K-2 occupation, but never deployed to Southwest Asia or K-2. K2SP will update health outcomes data on an annual basis over the next 8 years and will periodically analyze disease outcomes and causes of death during this time frame. Additionally, K2SP will provide the capability to rapidly assess any new health concerns that emerge.
In early 2022, K2SP began assembling the longitudinal health outcomes database, with the initial assessment of disease outcomes planned for completion by the summer of 2022. K2SP will then begin analyzing causes of death, with a final report anticipated in late summer of 2023. For ongoing updates and other K-2 related information please go to our K-2 webpage.
Resources on military environmental exposures
VA’s Health Outcomes Military Exposures (HOME) strives to provide the most comprehensive, helpful information to Veterans about military environmental exposures and health and about our Environmental Health Registry programs. Below is information about our exposure resources and our office’s effort to make them as up-to-date, widely known, and useful as possible.
Airborne Hazards and Burn Pits: In early 2021, we updated the Airborne Hazards and Open Burn Pit web pages. You can find links covering general information, the Airborne Hazards and Open Burn Pit Registry, research, how to get care, information for health care providers, and frequently asked questions. We also advertised the registry through social media efforts; through Facebook and Google ads and other platforms, such as Rally Point and We Are the Mighty; and in 17 radio interviews across the country.
In addition, the Airborne Hazards and Burn Pits Center of Excellence within the War Related Illness and Injury Study Center (WRIISC), an office within HOME, conducted 4 listening sessions during the summer of 2021 to facilitate two-way communication between the Center and Veterans who are interested in ongoing efforts surrounding the study of airborne hazards and burn pits.
Educational Classes and Podcasts: The WRIISC offers a Veteran environmental exposure education class series virtually via WebEx. Also, the WRIISC has an ongoing podcast series for Veterans, their caregivers, and the healthcare community called Veterans Heath Matters. Twelve episodes have been produced since July 2020.
Online resources: For extensive information about military exposures and health, visit Military Exposures - Public Health (va.gov). Topics include chemical, physical, and environmental hazards during military service, VA programs, benefits, research studies, and provider resources. The WRIISC also offers information about post-deployment health concerns at War Related Illness and Injury Study Center Home (va.gov).
HOME offers the Exposure Ed app to help health care providers provide information to Veterans on health effects associated with certain exposures during military service. Features of the app include the ability to search for information on exposures by specific exposure name, date and location of military service, or conflict. It also includes information about potential health effects from these exposures and related VA programs and policies. This app is available for free download on Apple and Android devices.
In addition, the website MyHealtheVet offers tips and tools to help you partner with your VA health care team, so together you may work to manage your health. The following articles on MyHealtheVet cover military environmental exposure topics:
- Join the Airborne Hazards and Burn Pit Registry - My HealtheVet (va.gov)
- Gulf War Illness: Here's an App for That - My HealtheVet (va.gov)
- VA Mobile Apps - My HealtheVet Find links to VA’s Exposure Ed app and Airborne Hazards and Open Burn Pit Registry.
Radiation cleanup update- Palomares and Enewetak
Health Outcomes Military Exposures is following nuclear cleanup projects at the Enewetak Proving Ground at Enewetak Atoll and at Palomares, Spain. While these cleanup projects may have affected some Veterans, radiation doses at Enewetak Proving Ground and Palomares are below those known to cause adverse health effects.
Enewetak Proving Ground
At the Enewetak Proving Ground in the Marshall Islands in the Pacific Ocean, the U.S. conducted nuclear tests from 1948 through 1958. Approximately 6,000 Veterans and civilian personnel participated in a cleanup project from May 1977 through May 1980 as a part of a plan to return the atoll to the Trust Territory of the Pacific Islands. Veterans who participated in the cleanup of Enewetak Atoll encountered very low levels of radiological contamination, and current residents have little or no intake of residual radionuclides.
VA conducts ongoing surveillance of the health care utilization and mortality experience of Enewetak Veterans. A recent review found no increased risk of either overall cancer or specific cancer mortality among Veterans due to their military service on the Enewetak Atoll. Surveillance of VA health care utilization among 2,123 Enewetak Veterans who used VA services suggests that these Veterans do not have an unusual or elevated occurrence of disease, either for malignancies associated with radiation or other circulatory or respiratory diseases.
In 1966, a U.S. Air Force bomber and a tanker aircraft collided over Palomares, Spain, releasing four thermonuclear weapons. Two were damaged when they hit the ground, releasing plutonium, but with no nuclear detonation. Approximately 1,600 military and civilian personnel worked to decontaminate the site after the accident.
At Palomares, the Air Force found no evidence of adverse health effects from potential radiation exposure. There are no known health effects to the local Spanish population living in and around Palomares. VA researchers investigating health outcome data have not found an increase in disease or deaths related to radiation or patterns of health care utilization suggesting increased disease occurrence.
Our current knowledge about these low radiation exposures at Enetewak Proving Ground and Palomares do not support the addition of presumptive service connection for Veterans who served at these locations. Claims for benefits for Veterans serving at either location are considered on a case-by-case basis. VA will continue to monitor these Veteran populations into the future.
The Airborne Hazards and Open Burn Pit Registry – Purpose and location update
VA’s Airborne Hazards and Open Burn Pit Registry (AHOBPR) is designed to gather information from Veterans and service members about airborne hazard exposures and any related health conditions. It is for those who were deployed to the Southwest Asia theater of operations in Iraq, Kuwait, Saudi Arabia, Bahrain, Gulf of Aden, Gulf of Oman, Oman, Qatar, United Arab Emirates, waters of the Persian Gulf, Arabian Sea, or Red Sea any time after August 2, 1990; or Afghanistan or Djibouti on or after September 11, 2001. In addition, you will be eligible to participate in the AHOBPR if you served in Syria or Uzbekistan since September 11, 2001, or Egypt since August 1990, once this feature is added to the registry programing early this summer.
We encourage you to participate in the AHOBPR because it can help you better understand your health and help VA better understand and respond to Veterans’ health care needs.
In addition, the AHOBPR:
- Captures information on exposures
- Documents this information in the medical record
- Can be a portal to other VA health care
Please note that the registry is separate from the VA disability compensation process and is not required to file a claim. It does not confirm exposure to environmental hazards during military service. During the claims process, VA will check your military records to verify exposure to the claimed environmental hazard or qualifying military service. If necessary, VA will set up a compensation examination for you.
Whole health at VA
Are you interested in improving your “whole health,” meaning not just your physical health, but also your mental health, connection to others, sleep, energy, ways to find personal growth, and more? VA health professionals across the country are part of VA’s transformation to a Whole Health system of care, which focuses on personalized health plans based on Veterans’ values, needs, and goals and supporting overall well-being and health.
VA Connection Plans, a Whole Health intervention program offered through the VISN 5 Mental Illness Research, Education, and Clinical Center, is a recently completed pilot program that helped Veterans set goals for their body, mind, and social connections. Martin Allen, a Navy and Air Force Veteran and post-9/11 expert with VA’s Health Outcomes Military Exposures, was contacted by VA Connection Plans to participate.
Allen joined the program and set goals to control his health challenges, destress, and improve his health during the pandemic. The program helped him lose 50 pounds, add walking to his exercise routine, and begin transcendental meditation.
“The VA Connection Plans program helped me to focus on my health goals and implement them,” said Allen. “Health care providers helped me with both my physical and mental health,” he added.
Though the VA Connection Plans program is on hiatus, you can learn more about Whole Health, create a personalized health plan, and talk to your health care provider about how you can incorporate Whole Health into your care. More Whole Health resources from VA are available at Whole Health Home, and you can find out how to get started at Get Started with Whole Health - Whole Health.
“She Wears the Boots” podcast covers military exposures
Listen to the military exposures episode on VA’s She Wears the Boots podcast and learn about exposures and health, how to obtain a registry exam, and information specific to women Veterans. Dr. Erin Dursa, senior epidemiologist with VA’s Epidemiology Program within Health Outcomes Military Exposures, presents this episode. She also discusses research on the health of 1990-1991 Gulf War Veterans and on Gulf War illness. You can find the “She Wears the Boots” podcast on Apple Podcasts, Spreaker, or anywhere you listen to podcasts.
Breast cancer and post-9/11 women Veterans
By Sally Haskell, MD, MS Deputy Chief Officer for Clinical Operations, Office of Women’s Health, Veterans Health Administration
Women Veterans who served since 9/11 may be concerned about an increased risk of breast cancer. VA acknowledges that there have been individual reports of breast cancer diagnoses among post-9/11 women Veterans in the news, and we are following this closely.
Current research shows:
- Based on Department of Defense (DoD), VA, and other data, there is no link between 1990-1991 Gulf War service and breast cancer. We continue to track breast cancer rates among women who served during the 1990-1991 Gulf War.
- A 2009 study (Zhu et al, Cancer Epidemiol Biomarkers Prev. 2009) compared breast cancer rates in military personnel to breast cancer rates among civilian women in the National Cancer Institute’s Surveillance Epidemiology and End Results program (SEER). The study found a slightly higher rate of breast cancer among military personnel. This may be because the military population had more known risk factors for breast cancer, such as delays in age of first childbirth or increased use of contraceptives. Another factor may be that military personnel had more access to routine screening, resulting in more identification of early-stage breast cancers, and resulting in higher measured rates.
VA Mammogram Services for Women Veterans
VA offers screening mammograms to women Veterans, following the American Cancer Society Guidelines. Our clinicians begin discussions about breast cancer with women at age 40. They start screening mammograms at age 40 for women who express an interest in early screening or who have a family history or other risk factors. Due to individual risks, some women may require even earlier screening. At VA, routine screening begins for all women no later than age 45. VA recommends screening yearly until age 54 and then every other year from age 55 onwards.
VA offers mammograms on-site at 69 VA facilities. For women receiving care at sites without mammography, we offer screening at conveniently located community facilities. VA sites have mammogram coordinators who track women who are due for a mammogram or follow-up on abnormal results and help our patients navigate through the breast cancer screening process.
VA exceeds the private sector in mammography screening rates. Like other health care agencies, we have seen some delays in routine screening related to COVID-19, but we are aggressively working to ensure all our patients are up-to-date on all preventive screenings.
For women diagnosed with breast cancer, VA offers full-service oncology treatment that includes imaging, surgery, chemotherapy, radiation, and other advanced state-of-the-art treatments as needed, either on-site, or in the community. VA patients are also eligible for enrollment in clinical trials.
In addition, VA is excited to be standing up a Breast Cancer System of Excellence. This will ensure the availability of nationally recognized, expert consultative services throughout VA, with electronic consultation, telehealth, and a virtual tumor board. The Breast Cancer System of Excellence will include a partnership with VA and non-VA research entities.
Health effects related to service at Camp Lejeune: Care, benefits, and federal research
Veterans who were stationed at Camp Lejeune (a U.S. Marine Corps Base in North Carolina) during the 1950s to 1980s may have been exposed to drinking water contaminated with industrial solvents from dry-cleaning waste and benzene from leaking underground fuels storage tanks. VA provides health and disability benefits for Veterans, Reservists, National Guard members, and family members who lived or worked at Camp Lejeune between August 1, 1953 and December 31, 1987 for at least 30 days. Additionally, VA collaborates with the Agency for Toxic Substances and Disease Registry (ATSDR) on studies to determine if additional conditions may result from this exposure.
Currently, VA provides qualifying Veterans with cost-free health care for the following 15 conditions:
- Certain cancers (esophageal, breast, kidney, lung, and bladder cancer)
- Multiple myeloma
- Non-Hodgkin’s lymphoma
- Renal toxicity
- Female infertility
- Myelodysplastic syndromes
- Hepatic steatosis
- Neurobehavioral effects
For the above conditions, family members of military personnel who lived at Camp Lejeune are eligible for reimbursement of out-of-pocket medical expenses not already covered by their other health plans.
For Veterans and Reserve and National Guard members, VA has established presumptive service connection for eight health conditions associated with exposure to contaminants in the water supply. This means VA presumes that service at Camp Lejeune caused the conditions and provides disability compensation without additional proof. These conditions are:
- Adult leukemia
- Aplastic anemia and other myelodysplastic syndromes
- Bladder cancer
- Kidney cancer
- Liver cancer
- Multiple myeloma
- Non-Hodgkin's lymphoma
- Parkinson's disease
VA has partnered with ATSDR to closely monitor the health of Camp Lejeune Veterans. ATSDR has performed a series of health studies on this population and is currently conducting its final studies: an assessment of vapor intrusion as a source of exposure to the contaminants in the water supply and a study of cancer incidence in the population. Once ATSDR’s studies are complete, they will transfer the study cohorts to VA’s Health Outcomes Military Exposures to continue follow-up studies on the health of this population over time. This will allow VA to update its policies regarding care and compensation for Camp Lejeune Veterans.
For more information on ATSDR’s Camp Lejeune studies, visit: https://www.atsdr.cdc.gov/sites/lejeune/health-effects.html.
WRIISC study on Veterans and COVID-19
Deployed Veterans may be at greater risk of long-term health effects from COVID-19 due to their deployment and exposure histories. Therefore, the War-Related Illness and Injury Study Center (WRIISC) is planning a study to understand the health effects of COVID-19 specifically among deployed Veterans.
The WRIISC is studying participants from the Airborne Hazards and Open Burn Pit Registry who have had COVID-19 to learn about long-term symptoms, lingering effects, and how common it is for Veterans to have long-COVID. The study will include up to 375 Veterans with a documented positive test, with additional females and non-white Veterans included in the study.
Researchers will interview study participants over the telephone or through a VA-approved web-based platform. The interview will include:
- questions about experiences during and after COVID-19 infection, current symptoms, and recent exposures
- a COVID-19 questionnaire from SubPopulations and InteRmediate Outcome Measures in COPD Study (SPIROMICS)
- the CDC Chronic Fatigue Syndrome Symptom Inventory, Multidimensional Fatigue Inventory (MFI)
- the Dyspnea-12 (D-12) Questionnaire
- the Modified Medical Research Council (mMRC) dyspnea scale
- questions on demographic, socioeconomic and behavioral factors
Researchers will follow-up with participants every six months through 24 months from their positive COVID-19 diagnosis. They will analyze data collected from participants to distinguish between Veterans with and without long-COVID.
At the conclusion of this study, the researchers aim to determine the prevalence of long-COVID in their sampled group, characterize long-COVID symptoms and potentially associated factors, and tailor future studies regarding COVID in populations.
Research update: VA’s Epidemiology Program, Health Outcomes of Military Exposures
During 2021, VA’s Epidemiology Program within Health Outcomes of Military Exposures published several peer-reviewed publications on Veterans with military service since 1990. Below are summaries of some of our publications.
We reported health outcomes after 20 years using longitudinal data on 30,000 deployed and non-deployed Gulf War Veterans. The findings from this study suggest that Gulf War Veterans are not only more likely than their non-deployed counterparts to report chronic disease, but they are also more likely to report it earlier. This work continues, and we are planning a fourth survey of these study participants.
The Epidemiology Program is working to better describe and understand Gulf War illness. One study found that demographic and lifestyle factors and medical conditions from before the war are strong predictors of Gulf War illness. Another study looked at Gulf War illness in Veterans who participated in the Gulf War Era Cohort and Biorepository as a foundation for developing a case definition. Also, the Epidemiology Program is leading an artificial intelligence analytical project to develop a data driven approach to better define Gulf War illness.
Our Epidemiology Program team has also been actively assessing mortality among Gulf War Veterans and those who served during Operations Enduring Freedom, Iraqi Freedom, or New Dawn (OEF/OIF/OND). In an analysis of Gulf War Veterans 25 years after the war, researchers found no difference in disease mortality between deployed and non-deployed Veterans; however, female Veterans had a higher risk of suicide compared to the U.S. population.
A study on disease mortality among OEF/OIF/OND Veterans compared to the general U.S, population showed a lower risk of mortality overall, as well as for all respiratory-related diseases. Additionally, OEF/OIF/OND Veterans had a higher risk of mortality due to motor vehicle accidents and suicide compared to the U.S. population.
Other Epidemiology Program studies have looked at suicide among Veterans who served since 1990. In one study, homelessness and justice involvement were associated with more severe post-traumatic, depressive, and substance use symptoms among post-9/11 Veterans, along with increased rates of suicidal ideation and attempt, compared to post-9/11 Veterans with no history of homelessness or justice involvement. Another study found an increased risk of suicide among OEF/OIF/OND Veterans compared to non-Veterans. In addition, a study of OEF/OIF/OND Veterans found that reporting more than 6 adverse childhood experiences (ACEs) was associated with suicide attempt after age 18 for Veteran men. For Veteran women reporting ACEs, the strongest association with suicide attempt was found for suicidal ideation or attempt before age 18.
In addition to published research, Epidemiology Program staff support policy and research initiatives throughout VA. Several staff served on the respiratory presumptions review panel that contributed to three new respiratory presumptions for Veterans who served in Southwest Asia. One staff member served as co-chair of the task force to design of a new program within VA’s Office of Research and Development focused on improving objective measurement of military exposures. Through these efforts, the Epidemiology Program continues to supports VA’s mission to care for Veterans as concerns and exposure risks evolve.
Gulf War illness and a case definition
Gulf War illness (GWI) is a chronic, symptom-based condition that affects an estimated 30% of all Gulf War Veterans. It presents as a cluster of medically unexplained symptoms that include, but are not limited to, fatigue, pain, gastrointestinal upset, memory problems, headaches, skin rashes, and respiratory issues.
While many definitions have been proposed, there is no single, validated case definition for GWI. Several independent groups, including the National Academies of Science, Engineering, and Medicine and the U.S. Government Accountability Office, have recommended that VA develop a single case definition that would help VA improve the way in which GWI is diagnosed, improve the way in which disability claims are adjudicated, and improve the way research is conducted on Veterans with GWI.
Health Outcomes Military Exposures (HOME) is supporting two innovative projects using a data-driven approach to develop a single case definition for GWI. The first is a chart review project directed by the War Related Illness and Injury Center (WRIISC) in East Orange, NJ. Medical records from Gulf War Veterans who visited a WRIISC clinic between 2001-2018 have been under review to determine a case definition that best fits the clinical presentation. The second is an artificial intelligence analytical project co-led by HOME epidemiologists and the Harvard School of Medicine that leverages pre-deployment and deployment data from the Department of Defense and medical records from VA on over 500,000 Gulf War and Gulf War-era Veterans to identify predictors and clinical correlates of GWI. These projects were recently finished and HOME is reviewing reports to decide on next steps to potentially arrive at a clinical case definition.
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